Special report: are you on the right pill?

Since its introduction in 1961, more than 200 million women have used the pill.

It changed lives in the hedonistic haze of the 60s and even found fame on the cover of Time magazine. But do we really understand the pill?

It’s essential to think about whether your pill suits your body, says Jane Bennett, co-author of The Pill: Are You Sure It’s For You?.

“Many women forget it’s a drug,” she says. “The hormones change your biochemistry, which is a big deal. Is it the best contraception for you and can you live with the side effects?”

The pill is one of the most studied medications a doctor can prescribe, and conflicting reports about the safety and side effects of the tablet that allows us to make love not babies are common.

“It’s so widely studied, every nuance is reported,” says Women's Health health expert Dr Ginni Mansberg.

“While information’s great, it can be unnecessarily frightening if you don’t understand what the stats mean for you.”

To set the record straight, we’ve called the experts to give you the facts – and the best choice for you.

If you go to your doctor requesting contraception, many will offer you a hormone-based solution as a matter of course, says Bennett.

“It’s common for GPs to prescribe the pill simply because they know about it, rather than making sure it’s right for you. But we shouldn’t settle for a one-size-fits-all approach to contraception.”

Any discussion with your GP about contraception should involve a detailed conversation about your medical history, says Dr Ivana Borsky, senior doctor for sexual and reproductive healthcare at Marie Stopes International.

“If you have high blood pressure, circulatory disease, diabetes, liver problems, unusual vaginal bleeding or a history of blood clotting, then the pill isn’t for you. Women over 35 who smoke or are very overweight may also be advised to choose another method of contraception.”

If the pill is your best option, how do you ensure you receive an individually tailored prescription that actually benefits you, rather than something that sort of suits most people?

Initially, it can be difficult, admits Dr Deborah Bateson, senior medical coordinator at Family Planning NSW. It’s hard to predict how a patient will react to a specific pill, so the standard of care is to start with one – then switch to another if there are problems.

“Because all combined pills are equally effective at preventing pregnancy, we advise most women start with the most common type of pill and see how it suits them,” she says. “This is usually a combined monophasic pill [each pill contains the same dose of the synthetic hormones oestrogen and progestogen].”

This is not about doctors being lazy, she explains. “These pills have the lowest level of risk and are also the cheapest.”

RELATED: Women's Health pill-free contraceptives

But it’s not hard to help your GP make a more informed selection for you.

“Thinking properly about what you want from your pill will help your doctor narrow down your needs and prescribe you something more specific,” says Dr Mansberg.

If you want to combat heavy periods, acne or PMS as well as get contraceptive cover, your GP can choose a pill to help.

“Keep a log of how you feel physically and emotionally throughout your menstrual cycle, taking note of things like bloating, breast tenderness and low mood,” says Dr Mansberg. “Then you can pinpoint the issues you’d like to deal with and your doctor can prescribe a pill to maximise your health benefits.”

Once you start taking the pill, your hormones need to adjust, so keep a close eye on how you’re feeling.

“Some pills do have side effects, although generally symptoms settle down around the three-month mark,” says Dr Mansberg.

“If you’ve got a pill to help with acne, be aware that the fall guy is often your libido. Feeling unusually moody or low? Don’t ignore it. If you simply don’t feel right, go back to your doctor."

“There is a bit of trial and error in prescribing the right pill,” says Dr Bateson. “Not all pills suit all women, but something as simple as swapping types can get rid of your side effects.”

Your body off the pill

If your ovaries aren’t lulled into a sleep-like state by the pill, they would remain hard at work producing the majority of the oestrogen in your body. In the middle of the reproductive cycle just before ovulation, their oestrogen production would skyrocket.

That’s a signal to the brain that it’s time for one of the ovaries to release an egg. The extra oestrogen also triggers preparation of the uterine lining for a possible pregnancy. When the egg is released, the ovaries lower their oestrogen output and start producing large amounts of progesterone.

High levels of progesterone in the blood send a message to the brain that ovulation has occurred so it prevents the ovaries from releasing another egg.

If you were to become pregnant at this point, the ovaries would continue to make progesterone, which would help build up the uterine lining even more, as well as cause cervical mucus to get thick and sticky, preventing foreign substances including sperm from entering the uterus.

If you don’t become pregnant, production of oestrogen and progesterone drops to its lowest point. These low levels of hormones let the brain know the body isn’t knocked up, and for a few days the uterine lining weakens, sloughs off, and occasionally causes embarrassing moments and impossible-to-remove stains.

Your body on the pill

There are dozens of oral contraceptives available, but they all prevent pregnancy with synthetic hormones that confuse your reproductive system.

The most commonly used synthetic oestrogen in birth control pills is ethinyl estradiol (EE). The pill delivers a steady dose of EE that’s higher than the amount of oestrogen your body would normally produce. As a result, the oestrogen level in your blood never peaks in the same way it would if you weren’t on the pill, so there’s no signal to the brain to release an egg, and hence no baby.

RELATED: The benefits and drawbacks of the Pill

All pills that contain EE also contain synthetic progesterone, called progestogen. Known as combination pills, they combine the pregnancy-preventing effects of both hormones. Like EE, the levels of progestogen in the pill are higher than your body would usually produce, and that progestogen is present during your whole cycle rather than just two weeks after ovulation. The constantly high level makes pregnancy virtually impossible, keeping ovaries from releasing an egg and making the cervical mucus so thick and sticky that sperm is blocked from entering the uterus.

Some pills contain only progestogen and are known as POPs, or mini-pills. They rely largely on the hormones’ effect on cervical mucus to prevent pregnancy. Women who take progestogen-only pills get pregnant slightly more often than women on combination pills. This is because the progestogen in one pill only remains effective for 24 hours, so a new pill must be taken at the same time every day.

Now you know the basics, let’s move on to the finer points. Because that’s what can affect everything from your mood, to your skin, to your cramps, to how much hair grows on your upper lip. (NB: Every woman could respond differently to any given pill, these are just general guidelines.)

WHAT PILL ARE YOU

PILL TYPE 1

Combined pill with more oestrogen
MEDICAL SPECS 30 to 35 micrograms (mcg) of EE
plus progestogen.
BRAND-NAME EXAMPLES Microgynon30™, Nordette™, Levlen™, Monofeme™, Norimin(1)-28™, Brevinor-1(R)-28™, Yasmin™, Diane-35™, Estelle-35™, Juliet-35™, Brenda-35™, Valette™
DELIVERY METHOD The same amount of EE and progestogen is contained in every pill (monophasic).
USUALLY WORKS BEST FOR Women who experience vaginal dryness or breakthrough bleeding early in their cycle may benefit from the increased oestrogen. Also useful for women with heavy periods, as these can often reduce blood loss each month. A pill that delivers a consistent amount of hormones throughout the cycle can also have a stabilising effect physically and emotionally.
FINE POINTS Yasmin™ contains the progestogen drospirenone, which regulates water retention in the body and can reduce premenstrual bloating. All combined pills generally improve acne, but Diane-35™ and Valette™ contain an anti-androgenic (has anti-male hormone properties) progestogen that can reduce acne and sebum production. Microgynon30™ and Norimin(1)-28™ are available on the Pharmaceutical Benefits Scheme [PBS].

PILL TYPE 2

Combined pill with less oestrogen
MEDICAL SPECS 20mcg of EE plus progestogen.
BRAND-NAME EXAMPLES Microgynon20™, Loette™, Yaz™
DELIVERY METHOD The same amount of EE and progestogen is contained in every pill (monophasic).
USUALLY WORKS BEST FOR Women who have a lowered sex drive on pills with more EE. They may find that some problems are alleviated by a lower oestrogen pill. The low oestrogen dose means less likelihood of potential side effects, such as nausea, breast tenderness, bloating and headaches, and can also be useful for women with acne.
FINE POINTS 20mcg of oestrogen is the smallest amount available in an oral contraceptive. Because the oestrogen is lowered there is a higher chance of breakthrough bleeding. Yaz™ offers 24 active pills and four sugar pills [instead of the usual 21 active pills and seven sugar pills] and may be useful for treating emotional and physical premenstrual symptoms such as low mood and bloating. Low-dose pills are slightly more expensive than those with higher oestrogen content.

PILL TYPE 3

Combined multiphasic pill
MEDICAL SPECS Unique to each pill, but most remain within the range of 20 to 40mcg of EE and 50 to 125mcg of progestogen.
BRAND-NAME EXAMPLES Trifeme™, Triphasal™, Triquilar™, Logynon™
DELIVERY METHOD Levels of EE or levels of progestogen vary throughout the course of the cycle.
USUALLY WORKS BEST FOR Reducing the side effects of older oral contraceptives, including breakthrough bleeding. Since they were developed, however, several brands of the pill contain only 20mcg of EE, and the levels of synthetic oestrogen in multiphasic pills are no longer significantly lower, nor are the levels of progestogen.
FINE POINTS The fluctuating amounts of hormones mean these pills may result in cyclical mood swings in some women.

PILL TYPE 4

Third generation pills
MEDICAL SPECS 30mcg of EE and 75 to 150mcg of progestogen.
BRAND-NAME EXAMPLES Marvelon™, Minulet™, Femoden™
DELIVERY METHOD The same amount of EE and progestogen is contained in every pill (monophasic).
USUALLY WORKS BEST FOR Women who have had breakthrough bleeding, acne or excess hair growth on other pills.
FINE POINTS Third generation pills contain the synthetic progestogens known as desogestrel or gestodene and were developed to combat side effects of other oral contraceptives such as bloating. These pills have been found to have a slightly
increased risk of blood clots in relation to the low-dose pills. They’re not listed on the PBS, so are often more expensive.

PILL TYPE 5

Progestogen-only pills (mini-pill or POPs)
MEDICAL SPECS 30mcg levonorgestrel (progestogen) or 350mcg norethisterone (progestogen).
BRAND-NAME EXAMPLES Micronor™, Microlut™, Noriday™
DELIVERY METHOD Each pill contains the same amount of progestogen in a 28-day cycle. There are no placebo pills.
USUALLY WORKS BEST FOR Breastfeeding mums. Synthetic oestrogen has been shown to lessen the quantity of breast milk when given less than six weeks after delivery. As these mini-pills or POPs don’t contain oestrogen, they have no effect on a woman’s breast milk.
FINE POINTS It is essential that mini-pills or POPs are taken at the same time every day, otherwise their effectiveness will be reduced. This type of pill is only a wise choice for women who are good timekeepers.

The future of the pill

The first pill containing “natural” oestrogen. Called Qlaira®, it contains the oestrogen estradiol valerate, and was recently released in Europe. Keep in mind that “natural” oestrogen is still a synthetic hormone.

“Quite often these oestrogens are actually made from plants in a factory,” says Dr Jane Elliott of the Menopause Clinic in the Women’s Health Centre at Royal Adelaide Hospital.

It’s marketed as “natural” because it’s an identical copy of our main oestrogen, oestradiol, and when it binds with an oestrogen receptor, the receptor can’t tell the difference.

At the moment, there’s little research to prove it’s actually a better choice. The first international trial examining its efficacy and safety, involving researchers from The University of Adelaide, began in 2006, and a similar worldwide trial started earlier this year to see if “natural” oestrogen triggers fewer side effects than conventional synthetic hormones.

Researchers believe it may be the answer for some pill users experiencing painful, heavy periods, low libido and other crappy symptoms related to the drug. It’s been approved by the Therapeutic Goods Administration, but there’s no news – yet – on when it’s hitting Oz.

Visit Contraceptioninfo or Sexual Health and Family Planning Australia for more info.

The pill that could increase libido. But don’t get too excited... it’s also still at the trial stage. Sydney’s Royal Hospital for Women is conducting a trial of a new oral contraceptive that could make you hornier, since up to 10 per cent of birth control pill takers report a decrease in libido. If you’re one of them, watch this space.

– Susie Cameron & Alice Ellis